MINISTRY OF HEALTH

INSTITUT LATIHAN KEMENTERIAN KESIHATAN

JOHOR BAHRU, MALAYSIA

CASE STUDY
TOPIC: ANTRAL ULCER (FORREST 2A) & DUODENAL ULCER
(FORREST 1B)

NUR HANI NASZLIN BINTI HUSSIN

PBGI 1/2019(S)-0015

MENTOR : SIR EIRZANI BIN OTHMAN

GASTROINTESTINAL ENDOSCOPY COURSE

MARCH 2019 INTAKE

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 CONTENTS

NO TITLE PAGE

1 Acknowledgement 3

2 Patient History 4-5

3 Case Scenario 6-7

4 Anatomy & Physiology 8-13

5 Disease / Condition 14-15

6 Pathophysiology 15

7 Clinical Manifestation 17-18

8 Medical Management

1. Endoscopic Procedure 19-27

2. Medications 28-29

9 Nursing Management 30-35

10 Health Education 36

11 Summary 37

12 References 38

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 ACKNOWLEDGEMENT

I’m glad that being selected by KKM to join this Gastrointestinal Post Basic Course at

ILKKM Johor Bahru. Besides, I’m grateful that I be able to complete my case study that

assigned to me.

Thus, I would like to take this golden opportunity to thanks to my tutor as well as my

mentor, Encik Eirzani as guidance during my stay and for my post basic course.

Furthermore, special thanks to physicians, surgeon and sister for allowed my group to

posting at Hospital Selayang and Hospital Kuala Lumpur. I also would like to thanks to

all endoscopy staffs from both hospitals for sharing their knowledge and guidance

especially when I a doubt and supervision during my attachment at endoscopy unit.

Last but not least, I would like to thanks all my fellow colleagues who very supportive

and guide me during this case study and able to complete it.

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 PATIENT HISTORY

PATIENT BACKGROUND

Name : Madam Z

Age : 51 years old

Date of birth : 18 August 1968

Gender : Female

Race : Malay

Height : 155cm

Weight : 63kg

Occupational : Housewife

Marital status : Married

Admission date : 25th June 2019

Discharge date : 28th June 2019

MRN : 264171*

Diagnosis : Forrest 2A Antral Ulcer, Forrest 1B at D1

Procedure performed : OGDS with Injection Adrenaline, gold probe and Haemoclip

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HISTORY OF PATIENT

Medical History : Diabetes, Hypertension, Hyperlipidemia

Surgical History : Nil

Allergies : Nil

Medication : T.Metformin 500mg BD, T.Amlodipine 5mg BD, T.Crestor 10mg ON

Family History : Mother has diabetes

Social History : Non smoker, not on alcohol, not exercise, has 3 children (age 24, 22

and 17 years old)

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 CASE SCENARIO

On 25th June 2019 around 1230hrs, patient came in to emergency department of

Hospital Kuala Lumpur accompanied by husband. Patient came in with complaint of

abdominal pain for a week, passing of melena stool 2/7, fatigue, loss of appetite. Patient

also claimed that she vomited small amount of coffee ground colour before went to

hospital.

Patient admitted for further investigation and plan for emergency

Oesophagogastroduodenoscopy (OGDS)

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Various test taken prior OGDS such as for blood are Full Blood Count (FBC), Renal

Profile, Coagulation profile, group and crossmatch as standby. Chest xray, lung

auscultation, per rectum also done.

BLOOD INVESTIGATION RESULT

Haemoglobin (HB) : 8.2 (normal range 12.2-18.1g/dL)

White Blood Count : 13 (normal range 4.0-10.20 /UL )

Platelet Count : 387 (normal range 142-424/UL)

Urea : 26.8 (normal range 2.5- 6.4 mmol/L)

Potassium : 3.7 (normal range 3.5 -5.1 mEq/L )

Sodium : 136 (normal range 135 – 145 mEq/L)

Prothrombin Time (PT) : 11.1 (normal range 11-13.5seconds)

APTT : 30.6 (normal range 30-40seconds)

INR (International Normalized Ratio) : 1 (normal range 0.8-1.2 )

Blood group : B+

Chest xray : Normal

Lung auscultation : Normal

Per rectum : melena stool seen

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 ANATOMY AND PHYSIOLOGY

The stomach, which is roughly “J” shaped, stretches from the esophagogastric junction

to the pylorus. The pylorus is a definite musculofibrotic sphincter also known as the

muscle of Torkildson. The stomach is divided into the following anatomic sections. The

fundus is the area superior to and to the left of the esophagogastric junction the body,

the largest part of the stomach, is interposed between the fundus and the gastric

antrum. The antrum, the distal portion of the stomach, extends roughly from the gastric

angularis to the pylorus; a tongue of gastric antrum extends higher proximally on the

lesser curvature of the stomach; and the Cardia is a zone approximately 3 cm wide

distal to the

esophagogastric junction.

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Regions of the stomach

The stomach is divided into 5 regions:

 The cardia is the first part of the stomach below the esophagus. It contains the

cardiac sphincter, which is a thin ring of muscle that helps to prevent stomach

contents from going back up into the esophagus.

 The fundus is the rounded area that lies to the left of the cardia and below the

diaphragm

 The body is the largest and main part of the stomach. This is where food is mixed

and starts to break down.

 The antrum is the lower part of the stomach. The antrum holds the broken-down

food until it is ready to be released into the small intestine. It is sometimes called

the pyloric antrum.

 The pylorus is the part of the stomach that connects to the small intestine. This

region includes the pyloric sphincter, which is a thick ring of muscle that acts as a

valve to control the emptying of stomach contents (chyme) into the duodenum

(first part of the small intestine). The pyloric sphincter also prevents the contents

of the duodenum from going back into the stomach.

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Layers of the stomach wall

The stomach is made up of several layers of tissue:

 The mucosa (mucous membrane) is the inner lining of the stomach. When the

stomach is empty the mucosa has a ridged appearance. These ridges (rugae)

flatten out as the stomach fills with food.

 The next layer that covers the mucosa is the submucosa. It is made up of

connective tissue that contains larger blood and lymph vessels, nerve cells and

fibres.

 The muscularis propria (or muscularis externa) is the next layer that covers the

submucosa. It is the main muscle of the stomach and is made up of 3 layers of

muscle.

 The serosa is the fibrous membrane that covers the outside of the stomach. The

serosa of the stomach is also called the visceral peritoneum.

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The duodenum is the first part of the small intestine (5-7 m), followed by the jejunum

and ileum (in that order); it is also the widest and shortest (25 cm) part of the small

intestine. The duodenum is a C-shaped or horseshoe-shaped structure that lies in the

upper

abdomen near the midline.

The pylorus of the stomach (at L1 level) leads to the duodenum, which has the following

4 parts:

 The first (superior) part, or duodenal bulb or cap (5 cm), which is connected to

the undersurface of the liver (porta hepatis) by the hepatoduodenal ligament

(HDL), containing the proper hepatic artery, portal vein, and common bile duct

(CBD); the quadrate lobe (segment IV) of the liver and the gallbladder are in front,

whereas the CBD, the portal vein (PV), and the gastroduodenal artery (GDA) are

behind the first part of the duodenum.

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  The second (descending) part (10 cm), which has an upper and a lower genu

(flexure); the transverse mesocolon and transverse colon are in front, and the right

kidney and inferior vena cava (IVC) are behind it; the head of the pancreas lies in

the concavity of the duodenal C at the level of L2 vertebra

 The third (horizontal) part (7.5 cm) runs from right to left in front of the IVC and

aorta, with the superior mesenteric vessels (the vein on the right and the artery on

the left) in front of it

 The fourth (ascending) part (2.5 cm) continues as the jejunum

The wall of the duodenum contains the same 4 layers that are seen in the remainder of

the small bowel--namely, the mucosa (lined with columnar epithelium, containing lamina

propria and muscularis mucosa), the submucosa, the muscularis propria (with inner

circular and outer longitudinal layers), and the serosa (only on its anterior surface). The

duodenal mucosa is characterized by the presence of Brunner’s glands, which secrete

mucus. Endocrine cells in the duodenal wall produce cholecystokinin and secretin.

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 DISEASE AND CONDITION

Madam Z send to Endoscopy unit after admitted in ward

Madam Z was seen by Dr. L, explanation given to patient and consent taken for OGDS

procedure. Dr L was performed the procedure and assisted by a gastrointestinal nurse.

Dr. L and nurse in charge found visible vessel at Antrum and as Dr scope further down,

oozing seen at ulcer in D1.

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As for oozing ulcer at D1, Dr L use Adrenaline injection first to stop the bleed.

Adrenaline 1ml (0.1 mg) dilute with 9mls of normal saline make it 10mls in 10mls

syringe. Total used about 6mls after dilutions. Then haemoclip x4 applied to secure the

bleeding. Visible vessel at Antrum, Dr L firstly secured with haemoclip x2 and Injection

Gold probe applied.

Biopsy of tissue was taken for Helicobacter Pylori test (CLO Test).

PEPTIC ULCER DISEASE

Peptic ulcer disease can develop in the lower esophagus, stomach, pylorus, duodenum

or jejunum. About 80 percent of all peptic ulcers are duodenal ulcers. They occur when

the protective mucosa of the duodenum cannot resist corrosion by above normal

hydrochloric acid levels. The predominant causes are infection with Helicobacter pylori,

a spiral bacteria that transmitted by gastro-oral route. Symptoms of duodenal ulcers

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include burning epigastric pain occurring after meals, heartburn and intermittent

nighttime pain, loss of appetite, and weight loss.

Acute ulcers and erosions present clinically with gastrointestinal bleeding or perforation.

If they heal there is no predictable recurrence. Factors concerned with mucosal defense

are relatively more important than aggressive factors such as acid and pepsin. Local

ischemia is the earliest recognizable gross lesion. The gastric mucosa is at least as

vulnerable as the duodenal mucosa and probably more so. Most drug-induced ulcers

occur in the stomach.

Peptic ulcers are defects in the gastric or duodenal mucosa that extend through the

muscularis mucosa. The epithelial cells of the stomach and duodenum secrete mucus in

response to irritation of the epithelial lining and as a result of cholinergic stimulation.

The superficial portion of the gastric and duodenal mucosa exists in the form of a gel

layer, which is impermeable to acid and pepsin.

PATHOPHYSIOLOGY OF PEPTIC ULCER DISEASE

In the absence of NSAIDs and gastrinoma, it appears that most gastric ulcers and all

duodenal ulcers occur in the setting of H. pylori infection. Duodenal ulcer is typified by

H. pylori infection and duodenitis and in many cases impaired duodenal bicarbonate

secretion in the face of moderate increases in acid and peptic activity. These facts

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suggest the following process: increased peptic activity coupled with decreased

duodenal buffering capacity may lead to increased mucosal injury and result in gastric

metaplasia.

In the presence of antral H. pylori, the gastric metaplasia can become colonized and

inflamed. The inflammation or the infection itself then disrupts the process of mucosal

defense or regeneration resulting in ulceration. A cycle of further injury and increased

inflammation with loss of the framework for regeneration may then cause a chronic

ulcer. Gastric ulcer often occurs with decreased acid-peptic activity, suggesting that

mucosal defensive impairments are more important.

CLINICAL MANIFESTATIONS

The classic symptom of a stomach ulcer is indigestion, also called dyspepsia.

Indigestion causes pain or discomfort in the stomach area. This symptom can be

mistaken for heartburn, which can occur at the same time. Heartburn can be caused by

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acid reflux or gastroesophageal reflux disease (GERD). It occurs slightly higher up from

the stomach and is felt in the lower part of the chest.

Stomach ulcer symptoms tend to be more distinct than heartburn, but symptoms can

still be vague. An ulcer tends to produce a burning or dull pain in the stomach area. This

pain is sometimes described as a "biting" or "gnawing" pain. Some people may describe

a hungry sensation.

Bacteria. It’s called Helicobacter pylori (H. pylori), and as many as half of us carry it. Most

people infected with H. pylori do not get ulcers. But in others, it can raise the amount of

acid, break down the protective mucus layer, and irritate the digestive tract.

Certain pain relievers. taking aspirin often and for a long time, patient more likely to get a

peptic ulcer. The same is true for other nonsteroidal anti-inflammatory drugs (NSAID).

They include ibuprofen and naproxen. NSAIDs block your body from making a chemical

that helps protect the inner walls of stomach and small intestine from stomach acid.

Less often, ulcers may cause severe signs or symptoms such as:

 Vomiting or vomiting blood — which may appear red or black

 Dark blood in stools, or stools that are black or tarry

 Difficulty in breathing

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  Nausea or vomiting

 Unexplained weight loss

 Appetite changes

As for Madam Z she suffers abdominal pain for a week, passing of melena stool 2/7,

fatigue, loss of appetite. Patient also claimed that she vomited small amount of coffee

ground colour before went to hospital.

MEDICAL MANAGEMENT

Management of patients with overt upper gastrointestinal bleeding. Hemodynamic

status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified

based on features such as hemodynamic status, comorbidities, age, and laboratory

tests. Proton pump inhibitor (PPI) may be considered to decrease the need for

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endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is

generally performed within 24h. The endoscopic features of ulcers direct further

management.

Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy

(e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an

adherent clot may receive endoscopic therapy; these patients then receive intravenous

PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based

ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding

after endoscopic therapy is treated with a second endoscopic treatment; if bleeding

persists or recurs, treatment with surgery or interventional radiology is undertaken.

Procedure to be perform to Madam Z :

OGDS (oesophagogastroduodenoscopy) refers to the technique of optical instrument

and flexible endoscope is used to provide direct visualization of the upper

gastrointestinal tract of the oesophagus, stomach, first part and second portions of

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small intestine for purpose of diagnosis and treatment of disorder of upper

gastrointestinal tract.

OGDS EQUIPMENT PREPARATION

 Basic equipment

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As a GIA endoscopy nurse, we have to ensure the procedure room is clean and tidy,

safety and all equipment functioning well. Below is the basic equipment are needed:

 Gastroscope - A flexible, lighted instrument that is put through the mouth and

esophagus to view the stomach.

 Light source and video processor

 Air water bottle - to supply air and water to the endoscope.

 Biopsy forceps - to take sampling of 1 to 3mm pieces of tissue under direct

vision.

 Mouth piece/mouth gag - placed between the teeth to prevent the patient biting

the endoscope.

 Incopad – cover pad.

 Topical Anaestetic (xylocaine 10%) - local anaesthatic used to numb the throat

during procedure and prevent gag reflex.

 Suction equipment-to clear the gaster from blood,mucous or any contents to get

the clear visualize.

 Kidney dish - to put sterile water for flushing during procedure.

 50cc syringe-to flush sterile water in gaster to clear the visualize during

procedure.

 Gauze-to wipe the endoscope from blood, mucous, secretion or any content from

patient after procedure.

 KY jelly - to lubricate the endoscope before and during procedure.

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 Specimen bottle-to put biopsy

 CLO test / Pronto Dry -for check helicobacter pylori.

 Disposable Injector 23G-for inject adrenaline to secure the bleeding.

 Adrenaline and Syringe 10cc and needle 18

 Water for injection 10mls – use to dilutes with Adrenaline for injection.

 Injector Gold Probe

 Haemoclip

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During OGDS on Madam Z is performed, Dr found Forrest Ulcer 2A at antral and

Forrest Ulcer 1B at D1.

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 ENDOSCOPIC PROCEDURE

Endoscopic techniques also used in the treatment especially in bleeding case include:

 Epinephrine injection

 Gold probe

 Heater probe

 Argon plasma coagulation (APC)

 Haemoclip

 Endo clot

All the techniques above suitable to use depends on the case and the physician or

surgeon. Madam Z was seen by Dr. L, explanation given to patient and consent taken

for OGDS procedure. Dr L was performed the procedure and assisted by a

gastrointestinal nurse. Dr. L and nurse in charge found visible vessel at Antrum and as

Dr scope further down, oozing seen at ulcer in D1.

As for oozing ulcer at D1, Dr L use Adrenaline injection first to stop the bleed.

Adrenaline 1ml (0.1 mg) dilutes with 9mls of normal saline make it 10mls in 10mls

syringe. Total used about 6mls after dilutions. Then haemoclip x4 applied to secure the

bleeding. Visible vessel at Antrum, Dr L firstly secured with haemoclip x2 and Injection

Gold probe applied.

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Biopsy of tissue was taken for Helicobacter Pylori test (CLO Test).

Injection Adrenaline

Injection with solutions of diluted epinephrine (1:10,000) is widely used because of its

simplicity. All that is required is a sclerotherapy needle, and the technique is simple. The

principal mechanism of action by which diluted epinephrine solutions work is a

tamponade effect induced by the volume of solution injected.

Injection Gold Probe

The Injection Gold Probe Catheter is indicated for use in endoscopic injection therapy

(to deliver pharmacological injection agents, such as vasoconstrictors) and endoscopic

electrohemostasis (cauterization of tissue and coagulation of blood) of actual or

potential bleeding sites in the gastrointestinal tract.

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Haemoclip

Haemoclips can achieve immediate hemostasis by obstructing the vessel and have the

special advantage of lack of additional tissue damage.

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Below are images during OGDS of Madam Z

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 MEDICATIONS

IV Pantoprazole 40mg (Proton Pump Inhibitor)

Patients with acute upper GI bleeding be started empirically on an intravenous (IV 40

mg IV twice daily after an initial bolus of 80 mg IV). It works by decreasing the amount of

acid stomach makes. The PPI can be started at presentation and continued until

confirmation of the cause of bleeding. Once the source of the bleeding has been

identified and treated (if possible), the need for ongoing acid suppression can be

determined.

Tab Clarithromycin 500 mg BD

 Tablet Clarithromycin is antibiotic used to treat a wide variety of bacterial

infections and works by stopping the growth of bacteria.

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  This medication also used in combination with anti-ulcer medications to treat

certain types of stomach ulcers.

 Take this medication by mouth with or without food usually every 12 hours and

follow doctor’s instruction. For the best, take it at the same times every day.

Tab Amoxicillin 1 g BD

 Amoxicillin ia an penicillin- type antibiotic to treat infections caused by bacterial.

 This medication also used with other medications to treat stomach/ intestinal

ulcers caused by the bacteria H pylori and prevent ulcers from returning.

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 NURSING MANAGEMENT

Madam Z came in to endoscopy department around 1406hrs. On arrival general

condition alert and orientated, patient looks lethargy. Patient last meal was at 0630hrs.

Pre Procedure :

- Firstly, I will verify informed and written consent from Madam Z or responsible

adult and make sure is correct patient by asking and checking patient’s name,

wristband with patient’s case note. Furthermore, make sure Madam Z has

nothing by mouth for 6 to 8 hours prior to procedure to prevent aspiration

pneumonia.

- Besides, obtain and document patient’s medical history and risk assessment

such as hypertension, heart problem, respiratory disease or allergies to ensure

patient will not have any complication during the procedure.

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- I documented the baseline vital sign e.g. Blood pressure, pulse rate, respiratory

rate and oxygen level. Baseline vital signs taken. Blood pressure : 149/72mmHg,

heart rate : 98bpm, SPO2 : 99% on room air, body temperature : 37’C,

respiration rate : 20bpm - to make comparison vital signs during procedure.

- On the other hand, to obtain laboratory result as required e.g FBC, PT/PTT, INR

this is to determine any abnormalities in blood coagulation.

- Reassurance and emotional support needed for Madam Z to reduce anxiety and

gain cooperation from patient during procedure.

- Ensure patient is not wearing any denture or jewelry and valuables is kept with

responsible adult.

- Finally, I reviewed and explained health education to Madam Z before sedation

to make sure patient understand and give some knowledge to the patient. For

daycare patient, discharge instruction will explain to them and make sure

someone will accompany the patient back to home.

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Intra Procedure

- Firstly, I will explain to Madam Z that the feeling numbness of the throat and taste
of the spray after topical anesthetic spray and topical anesthetic spray (Xylocaine
10% ) was spray to the back of throat of Madam Z to facilitate insertion of the
endoscope.

- Besides, put patient to left position to facilitate drainage of pharyngeal secretions

and mouth gag was placed to avoid patient bite the fiber scope.

- The procedure was done under sedation. IV Midazolam 3mg given to make

Madam Z comfortable. Vital sign monitoring monitored for blood pressure, pulse

rate, respiration rate, oxygen saturation, level of conciousness and document

every 5 minutes or more often if patient’s condition warrant.

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*Level of sedation

 0 = Awake.

 1 = Drowsy.

 2 = Sedated, Rousable with verbal comment.

 3 = Sedated, rousable with pain stimuli.

 4 = Unarousable.

- Furthermore, oxygen 3L/min via nasal prong to prevent hypoxia due to side effect

of sedation and to mantain oxygen saturation. I ensure that Emergency trolley

and reversal IV Flumazenil 0.5mg/5mls must be readily available in the

procedure room in case of patient’s condition worsen due to complication

happen.

- Frequently suctioning was done to keep airway clear and prevent aspiration.

- Madam Z was observed to any complication such as bleeding, hypoxia, cardiac

arrest and abdomen distended. No sign of condition noted.

- Assist doctor for biopsy / pronto dry and therapeutic procedures by GIA nurse.

- Documents vital signs, sedation given and patient condition.

Time 1415hrs 1420hrs 1425hrs 1430hrs

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 Blood pressure 150/79mmHg 145/75mmHg 141/70mmHg 138/65mmHg
Heart rate 95bpm 90bpm 87bpm 85bpm
Oxygen 100% 100% 100% 100%
saturation
Respiration rate 20bpm 20bpm 20bpm 20bpm

Level of sedation 2 2 2 2
Sedation IV Midazolam
3mg

Post procedure

Dr. L had reviewed patient CLO test and finding was explained to patient’s daughter

immediately after OGDS procedure completed.

 Madam Z was kept on his side untill fully awake and able to control secretion.

 Madam Z was observed in recovery area to monitor vital sign, blood pressure,

pulse rate, respiration rate, oxygen saturation and level of conciousness until it

returned to baseline before sent to ward.

Time 1435hrs 1440hrs 1445hrs

Blood pressure 140/78mmHg 138/75mmHg 141/80mmHg
Heart rate 87bpm 90bpm 88bpm
Oxygen 99% 99% 99%
saturation
Respiration rate 20bpm 19bpm 20bpm

Level of sedation 2 1 0
Pain score 0 0 0

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  Continued oxygen 3L/min via nasal prong to provide oxygenation.

 I observed sign and simptom of complication such as vomitting, abdominal pain

and abdomen distended. The Doctor will notified if these complication were

suspected.

 Documented all relevant finding in the post procedural checklist form.

Madam Z was send back to the ward and taken by ward staff and passing over done to

the staff around 2.45pm.

Endoscopic Findings

1. Forrest Ulcer 2A at antral.

2. Forrest Ulcer 1B at D1.

3. Clo test : +ve

Diagnosed as Peptic Ulcer Bleeding with presence of Helicobacter Pylori.

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 HEALTH EDUCATION

Madam Z discharged on 27 th June 2019. I explained to patient that she need to go to

hospital if symptoms like vomiting blood, melena stool seen. Patient also schedule for

follow up 1/12 is on 29th July 2019, I advised patient that she need to come for follow up

so doctor can see her treatment is working or not. I advised patient that she need to

take medication that prescribed by doctor.

Besides that, I explain the importance to maintain good nutritional habits and keeping a

healthy lifestyle to Madam Z to make her more understand. Some of the things she can

do include do not take any other counter or prescription drugs or herbal medications

without consulting with doctor or nurse because some medication may make liver

disease worse, avoid consuming coffee, tea, and spices as it is one of the factors that

can cause ulcer and advised to take small amount but frequent meal according to time

and avoid skipping meal.

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 SUMMARY

Madam Z age of 51 years old, came in to emergency department of HKL on 25 th June

2019. Patient came in with complaint of abdominal pain for a week, passing of melena

stool 2/7, fatigue, loss of appetite. Patient also claimed that she vomited small amount

of coffee ground colour before went to hospital. Through interview and history taking,

patient claimed she has diabetes mellitus, hypertension and high cholesterol. Patient

compliance with her medication.

Various investigation carried out and through blood test found HB 8.2 with patient

lethargic looking. Madam Z was referred to gastroenterologist and planned for

procedure emergency OGDS as to investigate source of bleeding.

An OGDS was performed, Doctor found Forrest Ulcer 2A at antral and Forrest Ulcer 1B

at D1. For antral ulcer use Adrenaline injection dilutes with 9mls of normal saline make it

10mls in 10mls syringe. Total used about 6mls after dilutions. Then haemoclip x4

applied to secure the bleeding. Visible vessel at Antrum, Dr L firstly secured with

haemoclip x2 and Injection Gold probe applied.

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Eradication therapy that include Proton Pump Inhibitor and antibiotic was ordered.

Patient discharged 2 days later with appointment on 29 th July 2019.

REFERENCES

Current Management of Peptic Ulcer Bleeding. (2006, January 13). Retrieved from

https://www.medscape.com/viewarticle/521189_1

Management of Patients With Ulcer Bleeding : American Journal of Gastroenterology.

(n.d.). Retrieved from

https://journals.lww.com/ajg/Fulltext/2012/03000/Management_of_Patients_With_Ulcer_

Bleeding.6.aspx

Berry, J. (n.d.). Bleeding ulcer: What causes it and is it serious? Retrieved from

https://www.medicalnewstoday.com/articles/318297.php

Bleeding Ulcer: Symptoms, Treatment, and More. (n.d.). Retrieved from

https://www.healthline.com/health/bleeding-ulcer

Metz, D. C., & Katzka, D. A. (2003). Esophagus and stomach. Edinburgh: Mosby.

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